I can't say that true "democratic groups," where every "partner" is exactly equal don't exist, because I know they do (maybe). But a pure "democratic group" where there is absolutely zero power inequality, even between those that have been in a group for 25 years, compared to those who've only been around 1-2 years, I would say are extremely rare. Just think about it. You've sucked it up through med school and residency, then you became partner at or even started an Emergency Medicine group. Over decades, a few doctors stay through the good times and the bad. More than a few come and go over the years for various reasons. You, having been one of the senior partners, who has probably been through contract negotiations, served on committees, may have served as your group's President, Vice-President or on the Board of Directors the last 25 years in the group. Yet after 25 years, some brand new baby doctor who's been out of residency only 12 months and hasn't done jack **** to ensure the survival of the group over time, and hasn't done anything but work shifts, expects to be fully equal?
You don't think the guys and gals at the top of the power structure haven't carved out some perk for themselves? You bet they have. It may not be a major pay differential. They may not be robbing the group or taking chunks of money so big they can retire on, but you bet your **** they've carved out some sort of inequality or non-democratic perk in there. Even if it's just more shares in the group, which will allow them a bigger pay out when they leave, or some stake in part of the group they built (billing company; buildings/labs/equipment if multispecialty).
Rest assured, there's likely to be something undemocratic and un-equal in even the most "democratic" small democratic groups. It may be more shares depending on time in the group, tiers of shareholder status/partnership, voting rights, or something else. Honestly, I think this concept to a large extent, is an endangered or near extinct intention of the first Emergency Physicians, sort of like the ideal commune that would exist perfectly in an alternate reality, if only...human nature was perfect, and naive and ideal. Most, likely started that way, but few likely exist in that ideal form.
The exception would be the youngest and smallest groups. For example, if you and 4 or 5 other people you just graduated from residency with, went to some back woods ED, that doesn't have a stable ER group, no board certified EPs and started your own group from the ground up. Sure, you're all equal. You all started on equal footing. But over the years, as you've been there longer, had more meetings with lawyers, accountants, hospital ceo's to wrestle out your contract, hired and fired docs, got a pension up and running, and dedicated your life's work to a group, are you really not going to carve out some perk, some unequal portion of the power structure and just hand over the reins to some brand new baby doctor who doesn't know a damn thing about any of it and who probably just wants to work a year or two to find himself, find out where he wants to live, and is likely going to jump at the next perfect rainbow-unicorn job out Texas way?
That being said, don't necessarily confuse "unequal" with you're "getting screwed." That's a mistake I see lots of people make. They show up day 1, they have ridiculously naïve ideas of being "democratic" and "equal" partners day one (or day 366) and when they find out on day whatever, that they're not exactly equal in every way, they conclude "I'm getting screwed" without ever really having an understanding what is or isn't happening and move on the next supposed Shangri La that isn't.
You're not going to be "equal democratic partner" day 366. I don't care what they tell you. I don't care if they tell you they have "open books." They are all (or almost all) going to tell you they have them. But who really cares if they have "open books." It doesn't mean anything because 99/100 new emergency physicians aren't going to open the books, or have any clue what sense to make of the mountains of spread sheets and profit and loss statements, tax returns, or billing and collection documents from the past 16 quarters. Are you going to hire an independent accountant or healthcare attorney to examine the books of the group that just hired you 2 months ago?
But don't stop there. Many groups are fair or are reasonably so. The "guys at the top" might skim a little. Of course. But so what? They have to. They're running and have run, a complex business. You haven't. Some groups might be screwing the docs at the bottom, content with frequent turnover and a feeding frenzy at the bottom over the scraps. Sometimes it can be very hard to tell the difference. If you're being paid fair market value, don't sweat it too much in the short run. Learn the group's insides and outs, and decide if you want to stick around 25 years to assume the control. Then spend the next 25 years earning your keep, and being of value to a group more than just being a clock puncher. Not that there's anything wrong with being a clock puncher. Just don't expect the keys to the castle handed over to you if you decide to be one.
Keep in mind that getting to the top of some EM SDG, may not even pay off that well. Some of these docs that have spent 25-30 yrs building and managing a group see it vaporize in a day when a hospital kicks them out for cheaper labor. This is not the way to get rich. After paying the docs, there's usually not a huge kitty left over to get rich on. Most EM groups have little if any brick and mortar assets. Sure, if you're at the top of a massive multistate mega group as the CEO or CFO, you're going to do well. But that's a rare few, with a special skill set in business that few if any of us can claim to have.
There is an entire spectrum and bell curve of how groups or physician corporations are structured, no matter how big or small. Some groups are more "democratic" than others. But a true "democratic" group, where all are 100% equal in every way, are the exception, not the rule. Some are very fair and more "democratic" than others. Some are screw jobs, but honestly, I think ER docs obsess over this more than they should a lot of the time, because they simply don't have any understanding or knowledge of what's going on monetarily in their group and assume the worst. Most of the quality groups know they have to pay a fair wage to keep people and most are going to do that.
The most important thing is whether or not you are being paid fair market value for your services in your market or region. If you don't know what that is, what that means, or how to determine it, then you need to figure it out. If you're getting paid fair market value, whatever that is, then the issue of what group structure you're in, is less important than if you're being paid below market value (although it's still somewhat important for monetary and other reasons). The main way you're going to make your money as an EP, is just by working your shifts over time. If you spend 25 years at a group, you're likely to make a little extra, but don't lose sleep over thinking others are getting rich off of it, because it's not likely to happen too often. Those that have, in most cases built something over time you didn't build and earned most if not all of it.
